Many doctors appear to believe they aren’t human — and don’t have normal human needs like the rest of us. At least according to two new studies recently released.

In an opinion piece published in Sunday’s New York Times, researcher Leeat Granek shares the results of two studies that suggest to her that, “Not only do doctors experience grief, but the professional taboo on the emotion also has negative consequences for the doctors themselves, as well as for the quality of care they provide.”

A different study released by the JAMA journal, Archives of Surgery, last week found that residents don’t get as much sleep as ordinary professionals get — which directly impacts their ability to concentrate and be mentally attentive.

Combined, these studies add to the picture that’s been painted for years by research — that doctors believe they are somehow “super human” and beyond the reach of normal human needs, for both their body and their mind. It’s a disturbing picture, and one that the medical education establishment needs to remedy sooner rather than later.

In the op-ed piece, researcher Granek summarizes the results of her study:

We recruited and interviewed 20 oncologists who varied in age, sex and ethnicity and had a wide range of experience in the field — from a year and a half in practice in the case of oncology fellows to more than 30 years in the case of senior oncologists. Using a qualitative empirical method known as grounded theory, we analyzed the data by systematically coding each interview transcript line by line for themes and then comparing the findings from each interview across all interviews to see which themes stood out most robustly.

We found that oncologists struggled to manage their feelings of grief with the detachment they felt was necessary to do their job. More than half of our participants reported feelings of failure, self-doubt, sadness and powerlessness as part of their grief experience, and a third talked about feelings of guilt, loss of sleep and crying.

While I agree that there very well may be a “professional taboo” on professionals expressing grief — and this is true of virtually all health and mental health professionals — I’d argue that, in the U.S. anyway, expression of grief isn’t exactly something most people do well to begin with.

Visit anyone’s viewing for a snapshot of how Americans handle their grief:
some people cry, others nod in awkward silence, still others make small talk. Very few people feel comfortable in their grief, and fewer still in expressing it.

So maybe it’s not a surprise that doctors don’t do it very well at all, either.

But what makes it different for doctors is that their lack of skills in dealing with their grief could very well impact their job and decision-making — negatively impacting other people’s lives too:

Even more distressing, half our participants reported that their discomfort with their grief over patient loss could affect their treatment decisions with subsequent patients — leading them, for instance, to provide more aggressive chemotherapy, to put a patient in a clinical trial, or to recommend further surgery when palliative care might be a better option. […]

Unease with losing patients also affected the doctors’ ability to communicate about end-of-life issues with patients and their families. Half of our participants said they distanced themselves and withdrew from patients as the patients got closer to dying.

Doctors (and therapists, too!) have a responsibility to acknowledge and appropriately cope with their own grief reactions. And heck, if they don’t have the skills to do so, they should learn them.

In the second study, 27 orthopedic surgery residents wore a wristwatch-type of measurement to gauge how often they slept. The average amount of daily sleep for the residents was just over 5 hours, with individual amounts ranging from 2.8 hours to 7.2 hours.

This lack of sleep is not good for their mental attention span:

The authors found that, overall, residents were functioning at less than 80 percent mental effectiveness due to fatigue during a mean of 48 percent of their time awake. Residents were also functioning at less than 70 percent mental effectiveness due to fatigue during a mean of 27 percent of their time awake.

Most docs are good people trying to do good in this world. But the more they act like they aren’t human and don’t have the same human needs and feelings the rest of us do, the more harm they bring to their patients.

By LEEAT GRANEK

MY mother died of breast cancer in 2005 after living with the disease for nearly 20 years. Her oncologist, whom I knew from the time I was 9 years old, was her doctor for most of that time. I practically grew up in the hospital, and my family felt quite close to the health care providers, especially the oncologist. After my mother died I wondered if the feeling was mutual.

Do doctors grieve when their patients die? In the medical profession, such grief is seldom discussed — except, perhaps, as an example of the sort of emotion that a skilled doctor avoids feeling. But in a paper published on Tuesday in Archives of Internal Medicine (and in a forthcoming paper in the journal Death Studies), my colleagues and I report what we found in our research about oncologists and patient loss: Not only do doctors experience grief, but the professional taboo on the emotion also has negative consequences for the doctors themselves, as well as for the quality of care they provide.

Our study took place from 2010 to 2011 in three Canadian hospitals. We recruited and interviewed 20 oncologists who varied in age, sex and ethnicity and had a wide range of experience in the field — from a year and a half in practice in the case of oncology fellows to more than 30 years in the case of senior oncologists. Using a qualitative empirical method known as grounded theory, we analyzed the data by systematically coding each interview transcript line by line for themes and then comparing the findings from each interview across all interviews to see which themes stood out most robustly.

We found that oncologists struggled to manage their feelings of grief with the detachment they felt was necessary to do their job. More than half of our participants reported feelings of failure, self-doubt, sadness and powerlessness as part of their grief experience, and a third talked about feelings of guilt, loss of sleep and crying.

Our study indicated that grief in the medical context is considered shameful and unprofessional. Even though participants wrestled with feelings of grief, they hid them from others because showing emotion was considered a sign of weakness. In fact, many remarked that our interview was the first time they had been asked these questions or spoken about these emotions at all.

The impact of all this unacknowledged grief was exactly what we don’t want our doctors to experience: inattentiveness, impatience, irritability, emotional exhaustion and burnout.

Even more distressing, half our participants reported that their discomfort with their grief over patient loss could affect their treatment decisions with subsequent patients — leading them, for instance, to provide more aggressive chemotherapy, to put a patient in a clinical trial, or to recommend further surgery when palliative care might be a better option. One oncologist in our study remarked: “I see an inability sometimes to stop treatment when treatment should be stopped. When treatment’s futile, when it’s clearly futile.” From a policy standpoint, this is an especially worrisome finding, given the disproportionately high percentage of heath care budgets spent on end-of-life care.

Unease with losing patients also affected the doctors’ ability to communicate about end-of-life issues with patients and their families. Half of our participants said they distanced themselves and withdrew from patients as the patients got closer to dying. This meant fewer visits in the hospital, fewer bedside visits and less overall effort directed toward the dying patient.

It’s worth stressing that most physicians want what is best for their patients and that the outcome of any medical intervention is often unknown. It’s also worth noting that oncologists and other physicians who are dealing with end-of-life issues are right to put up some emotional boundaries: no one wants their doctor to be walking around openly grief-stricken.

But our research indicates that grief is having a negative impact on oncologists’ personal lives and that there is a troubling relationship between doctors’ discomfort with death and grief and how patients and their families are treated. Oncologists are not trained to deal with their own grief, and they need to be. In addition to providing such training, we need to normalize death and grief as a natural part of life, especially in medical settings.

To improve the quality of end-of-life care for patients and their families, we also need to improve the quality of life of their physicians, by making space for them to grieve like everyone else.

Leeat Granek is a health psychologist and a postdoctoral fellow at the Hospital for Sick Children in Toronto.

In this week’s Torah portion, we confront one of the most difficult sections of Israelite sojourn in the desert. After forty years, as the people get near to finally entering the land, Moses loses his opportunity by disobeying G-d’s command and hitting the rock instead of speaking to it. I came across a unique and deeply touching read of the story from Chief Rabbi Lord Jonathan Sacks. He theorizes that Moses response is coming from a place of grief and mourning. When we are grieving, do we also often react in ways we know in our minds to not be the way we would want to respond? Perhaps this is what Moses was grappling with as well.

It is a scene that still has the power to shock and disturb. The people complain. There is no water. It is an old complaint and a predictable one. That’s what happens in a desert. Moses should have been able to handle it in his stride. He has been through far tougher challenges in his time. Yet suddenly he explodes into vituperative anger:

“Listen now, you rebels, shall we bring you water out of this rock?” Then Moses raised his arm and struck the rock twice with his staff. (Num. 20: 10-11)

It was such egregious behaviour, so much of an over-reaction, that the commentators had difficulty in deciding which aspect was worst. Some said, it was hitting the rock instead of speaking to it as God had instructed. Some said, it was the use of the word “we.” Moses knew that God would send water: it had nothing to do with Aaron or himself. Others, most famously Maimonides, said that it was the anger evident in the words “Listen now, you rebels.”

The question I want to raise is simply: what made this trial different? Why did Moses momentarily lose control? Why then? Why there? This question is entirely separate from that of why Moses was not allowed to enter the land. Although the Torah associates the two, I argue elsewhere that this was not a punishment at all. Moses did not lead the people across the Jordan and into the land because that task, involving a new generation and an entirely new set of challenges, demanded a new leader. Even the greatest figures in history belong to a specific time and place. Dor dor u-parnasav. “Each generation has its own leaders” (Avodah Zarah 5a). Leadership is time-bound, not timeless.

Behind Moses’ loss of emotional control is a different story, told with utmost brevity in the text: “In the first month the whole Israelite community arrived at the Desert of Zin, and they stayed at Kadesh. There Miriam died and was buried. Now there was no water for the community …” Moses lost control because his sister Miriam had just died. He was in mourning for his eldest sibling. It is hard to lose a parent, but in some ways it is even harder to lose a brother or sister. They are your generation. You feel the angel of death come suddenly close. You face your own mortality.

But Miriam was more than a sister to Moses. She was the one, while still a six- year-old child, to follow the course of the wicker basket holding her baby brother as it drifted down the Nile. She had the courage and ingenuity to approach Pharaoh’s daughter and suggest that she employ a Hebrew nurse for the child, thus ensuring that Moses would grow up knowing his family, his people and his identity.

Small wonder that the sages said that Miriam persuaded her father Amram, the gadol hador (leading scholar of his generation) to annul his decree that Hebrew husbands should divorce their wives and have no more children since there was a fifty per cent chance that any child born would be killed. “Your decree,” said Miriam, “is worse than Pharaoh’s. He only decreed against the males, yours applies to females also. He intends to rob children of life in this world: you would deny them even life in the world to come” (Midrash Lekach Tov to Ex. 2: 1). Amram admitted her superior logic. Husbands and wives were reunited. Yocheved became pregnant and Moses was born. Note simply that this midrash, told by the sages, unambiguously implies that a six year old girl had more faith and wisdom than the leading rabbi of the generation!

Moses surely knew what he owed his elder sister. She had accompanied him throughout his mission. She led the women in song at the Red Sea. The one episode that seems to cast her in a negative light – when she “spoke against Moses because of his Cushite wife,” for which she was punished with leprosy – was interpreted more positively by the sages. They said she was critical of Moses for breaking off marital relations with his wife Zipporah. He had done so because he needed to be in a state of readiness for Divine communication at any time. Miriam felt Zipporah’s plight and sense of abandonment. Besides which, she and Aaron had also received Divine communication but they had not been commanded to be celibate. She may have been wrong, suggested the sages, but not maliciously so. She spoke not out of jealousy of her brother but out of sympathy for her sister-in-law.

Likewise the sages understood the two events that preceded Moses’ crisis – Miriam’s death and the absence of water for the community – as connected. It was in Miriam’s merit, they said, that the Israelites had water during the desert years. A well (Miriam’s well) accompanied them on their travels, and when Miriam died, the water ceased.

So it was not simply the Israelites’ demand for water that led Moses to lose control of his emotions, but rather his own deep grief. The Israelites may have lost their water, but Moses had lost his sister, who had watched over him as a child, guided his development, supported him throughout the years, and helped him carry the burden of leadership by her role as leader of the women.

It is a moment that reminds us of words from the Book of Judges said by Israel’s chief of staff, Barak, to its judge-and-leader Deborah: “If you go with me, I will go; but if you do not go with me, I cannot go” (Judges 4). The relationship between Barak and Deborah was much less close than that between Moses and Miriam, yet Barak acknowledged his dependence on a wise and courageous woman. Can Moses have felt less?

Bereavement leaves us deeply vulnerable. In the midst of loss we can find it hard to control our emotions. We make mistakes. We act rashly. We suffer from a momentary lack of judgment. These are common symptoms even for ordinary humans like us. In Moses’ case however, there was an additional factor. He was a prophet, and grief can occlude or eclipse the prophetic spirit. Maimonides answers the well known question as to why Jacob, a prophet, did not know that his son Joseph was still alive, with the simplest possible answer: grief banishes prophecy. For twenty-two years, mourning his missing son, Jacob could not receive the Divine word. Moses, the greatest of all the prophets, remained in touch with God. It was God, after all, who told him to “speak to the rock.” But somehow the message did not penetrate his consciousness fully. That was the effect of grief.

So the details are, in truth, secondary to the human drama played out that day. Yes, Moses struck the rock, said “we” instead of “God,” and lost his temper with the people. The real story, though, is about Moses the man in an onslaught of grief, vulnerable, exposed, caught in a vortex of emotions, suddenly bereft of the sisterly presence that had been the most important bass-note of his life, Miriam, the precociously wise and plucky child who had taken control of the situation when the life of her three-month old brother lay in the balance, undaunted by either an Egyptian princess or a rabbi-father, Miriam who led the women in song, sympathised with her sister-in-law when she saw the price she paid for being the wife of a leader, Miriam in whose merit the people had water in a parched land, the quiet heroine without whom Moses was temporarily lost and alone.

The story of Moses and the rock is ultimately less about Moses and a rock than about a great Jewish woman, Miriam, appreciated fully only when she was no longer there.

One of the most interesting phenomenons in patient desire and wish is that many of them want their doctors to pray with them. The article below highlights some of the potential hazards and challenges physicians face when prayer is requested. Note the recognition that chaplaincy can be an integral aspect of care, though there is still a misconception that the chaplain’s role is primarily to help with prayer support. I tend to land on the side that a physician should be cautious about praying with a patient for reasons similar to what the physicians describe in this piece.

Research suggests that patients struggling with serious illnesses want spiritual interactions with their physicians. Some doctors wrestle with how to react.

Physicians are accustomed to fielding many challenging questions from patients, but there is one query that they may find especially flummoxing, considering the delicate terrain it requires them to traverse.

The question: “Doctor, will you pray with me?”

It’s not a far-fetched scenario. About two-thirds of patients believe doctors should know about their spiritual beliefs, said a survey of nearly 500 adults from Florida, North Carolina and Vermont in the January 2003 Journal of General Internal Medicine. One in five patients likes the idea of praying with the doctor during a routine office visit, while nearly 30% want to do so during a hospital stay, the study found. Half of patients would want to pray with the doctor in a near-death scenario.

About 75% of physicians say patients sometimes or often mention spiritual issues such as God, prayer, meditation or the Bible, said an April 9, 2007, article in Archives of Internal Medicine.

The question of whether it is appropriate for doctors to pray with patients was addressed in late May at a three-day conference organized by the University of Chicago Program on Medicine and Religion.

G. Richard Holt, MD, MPH, a recently retired otolaryngologist, gave a presentation reviewing his perspective as a head-and-neck surgeon.

During his 40-year career, Dr. Holt received about one or two prayer requests a month. He made it his practice to remain silent while the patient, a family member or religious leader prayed aloud. But Dr. Holt drew the line at initiating or leading prayer.

“Let’s say a physician tried to initiate a prayer and the patient was upset with it, because it caught them off guard or it was not something they felt was part of their relationship. … There could be some sort of investigation about this being an ethical breach,” said Dr. Holt, professor emeritus in the Dept. of Otolaryngology at the University of Texas Health Science Center at San Antonio.

“Being there silently with the patient during the prayer is, for the most part, a benign demonstration of validating the patient’s faith as being important to them,” added Dr. Holt, who is Presbyterian. “It does no harm to the doctor or the patient and usually does good. To me, once you start taking an active part in it, I’m concerned that it becomes different.”

Avoiding misunderstandings

Alan Astrow, MD, has crafted similar rules of thumb on praying with patients. Dr. Astrow, director of the Division of Hematology and Medical Oncology at Maimonides Medical Center in New York, believes it is appropriate to respectfully witness a patient’s prayer. However, he fears that leading a prayer could result in misconceptions about care.

“If they had some kind of a belief that something I specifically was saying had some kind of magical effect, I wouldn’t want to encourage that,” said Dr. Astrow, who is Jewish and also spoke at the religion and medicine conference. “I wouldn’t want to discourage patient belief, but I wouldn’t want to get into any practices that didn’t seem to be based in science.”

The question of how physicians should handle patient requests for prayer is not addressed in ethical guidelines issued by major physician organizations. The Joint Commission requires hospitals to conduct an assessment to determine what spiritual beliefs are important to patients or might affect their care, but does not cover physician-patient prayer.

Some physicians may feel uncomfortable, for personal reasons, about praying with patients. Seventeen percent of physicians never pray with patients, while 53% do so only when patients ask, according to a May 2006 Medical Care study based on a nationwide survey of nearly 1,200 physicians. One in 10 doctors has no religious affiliation, and one in three ranks low on a scale of self-reported religiosity, said the 2007 Archives survey.

Whatever their personal views, physicians ought to be aware of patients’ religious beliefs and work with pastoral-care providers to help address spiritual concerns, said Nancy Berlinger, PhD, a research scholar at The Hastings Center who has studied the role chaplains play in delivering quality care. About 60% of hospitals have chaplains on staff, according to the American Hospital Assn.

Berlinger agreed that there is little downside to respectfully observing a patient’s prayer. She advised doctors to be cautious in going beyond that when responding to patients’ religious requests. Most important, she said, physicians should expect such requests and have a plan for handling them that is consistent with their organization’s policies.

“You do not want to try to improvise here,” Berlinger said. “If there’s time, bring the chaplain in, who may be able to find out more about the nature of the request.”

Making spirituality part of care

Walter Larimore, MD, takes a more hands-on approach to integrating spirituality into his Colorado Springs, Colo., family practice. He is medical director of the charitable Mission Medical Clinic, which says it offers a “Christ-centered environment.” The clinic treats about 800 patients with chronic conditions who are uninsured and do not qualify for Medicaid.

Physicians at the clinic ask patients about their religious or spiritual beliefs as part of a routine history. They also ask patients what role they believe faith should play in care, and whether they would like to pray with doctors or volunteer lay ministers.

If patients are interested in prayer, Dr. Larimore notes it with a “P” in their charts. Care is not in any way contingent on openness to prayer or holding religious beliefs, he said.

Research has found that patients with strong religious beliefs and ties to a faith community have superior health outcomes, although the reason for that association is unclear. Studies of intercessory prayer — when a third party prays on behalf of the patient — have found little to no effect on outcomes and are widely regarded as lacking in methodological rigor.

Experts interviewed for this article were not aware of studies investigating the efficacy of physician-patient prayer. Only 6% of physicians believe religion and spirituality often help to prevent negative clinical outcomes such as heart attacks, infections or death, the Archives study said.

For Dr. Larimore, it is the deeper connections with patients facilitated by prayer that make an impression. In early June, a patient undergoing a family trauma came in with elevated blood pressure. After a drink of water, a visit with a nurse and a prayer, the woman’s diastolic blood pressure dropped about 20 points.

“Was there a cause and effect? I don’t know,” Dr. Larimore said. “But I could tell by the tears in her eyes that the experience touched her.”

For many, face to face encounters can be difficult to engage in. This has led to an increase in phone or other forms of therapy. According to the below article, it seems that the face to face aspect of care is not an absolute need and for many, this method of communication might work better for improving one’s well- being. Would the same hold true for supporting other mental and emotional ailments?

Talking to a psychologist on the phone as therapy for depression may work as well as meeting face-to-face, according to a new study.

Depression is common in the general population and psychotherapy is considered an effective treatment that some patients prefer to antidepressant medications.

The convenience of phones could make psychotherapy more readily available.(Charles Rex Arbogast/Associated Press)But about 75 per cent of patients with depression in previous studies said barriers like time constraints, lack of available and accessible services, transportation problems and cost stop them from going for treatment.

In Wednesday’s issue of the Journal of the American Medical Association, researchers compared treatments by randomly assigning 325 patients at community clinics in Chicago to face-to-face therapy or telephone therapy for 18 weeks.

“Our study found psychotherapy conveniently provided by telephone to patients wherever they are is effective and reduces dropout,” the study’s lead author, David Mohr, a professor of preventive medicine at Northwestern University Feinberg School of Medicine in Chicago, said in a release.

The results showed 20.9 per cent of the people who had therapy over the phone dropped out compared with 32.7 per cent for face-to-face therapy.

But those in the telephone group scored three points higher on a depression scale than those who met in person.

“The three point difference is of questionable clinical significance but it raises the question whether some individuals are at risk of worsening after treatment with telephone therapy compared to face-to-face,” Mohr said.

Overcoming barriers to treatment

The slight worsening could’ve been because those receiving phone treatment had more mental health difficulties and would’ve dropped out of in-person sessions altogether.

The possibility that face-to-face treatments creates better results for some can’t be ruled out, Mohr said. Physical presence could increase resilience or help people maintain their skills after treatment ends.

“The telephone offers the opportunity to extend care to populations that are difficult to reach, such as rural populations, patients with chronic illnesses and disabilities, and individuals who otherwise have barriers to treatment,” the study’s authors concluded.

“However, the increased risk of post-treatment deterioration in telephone-delivered treatment relative to face-to-face treatment underscores the importance of continued monitoring of depressive symptoms even after successful treatment.”

The researchers couldn’t think of any reasons why the findings wouldn’t apply to psychotherapy for other illnesses such as a anxiety disorders but that wasn’t specifically tested.

They were unable to mask the patients to the treatment, which could affect bias the results.

The research was funded by the U.S. National Institute of Mental Health of the National Institutes of Health.

One of the primary movers of hospice care is the volunteers who provide extra support and visits to pts. and families. Many hospices even provide for volunteers to be with the pt. during the last hours of life. The piece below describes these volunteers, usually referred to as vigil volunteers and the specialness of this support.

The woman, a grandmother who lived in New York City, was in her final hours when Abby Spilka came to sit by her bedside. The end was peaceful. “Watching her take her last breath was like watching a butterfly fall asleep, its wings fluttering progressively more slowly until they become motionless,” says Abby.

Abby is part of a dedicated corps of vigil volunteers in New York and around the country that embodies a key tenet of hospice care: that no one should die alone. “Human connection is very important at the end of life,” says Abby, who has been part of six vigils, is an active hospice volunteer and blogs about her experiences.

Abby and other vigil volunteers with whom I’ve spoken say that being with a person as they die is one of the most profound and intimate of human experiences. Alison Reynosa, who coordinates the vigil volunteers at the agency where I work, Visiting Nurse Service of New York Hospice and Palliative Care, puts it this way: “It’s an honor to be in someone’s presence as they take their last breath. It’s an amazing experience. It’s so important to be in the moment and just go with whatever happens.”

Vigil volunteers receive special training and are part of a team that works in shifts, to be there for the patient when doctors or other caregivers have determined that death is imminent — usually within 24 or 48 hours. Then Alison puts out the call, via email, for volunteers. Abby, for one, makes it a priority to answer the call. “When you’re sitting at your desk facing a deadline, with 42 emails to answer and the phone ringing off the hook, and you get email that says a complete stranger is dying alone, it gives you perspective,” she says.

The volunteers are already part of the hospice volunteer program, paying regular visits to a patient who has a life-limiting illness, offering emotional and practical support for patient and family. The vigil visit is quite different, and these volunteers receive an additional eight hours of training. Nurses, social workers, bereavement counselors and other experts speak to the volunteers about the physical, psychosocial and spiritual aspects of a person imminently dying, including what happens to the body as it shuts down.

Usually, vigil volunteers sit with a patient who has no family nearby, but sometimes family members have to step away briefly or need support themselves. Alison recalls how vigil volunteers supported a husband so he wouldn’t have to be alone as his wife of 50 years lay dying. “He was so open and honest,” Alison recalls of the husband. “He spoke about how they met, how they belonged to each other, what she was like. They had no children, and he was extremely grateful for that opportunity to speak to other people about how he felt about his wife.”

Tips for Sitting Vigil

1. Be Prepared — It is important for someone keeping vigil to be comfortable with death and dying. During training, VNSNY Hospice volunteers chart and reflect on their own experiences, including the first death they can remember, a “most difficult” death, and thoughts on who they would like to be with them in the room for their own death. Alison encourages vigil volunteers to keep a journal of their experiences.

2. Know What to Expect (But Expect the Unexpected) — Understanding what to expect is critical when sitting vigil. Training prepares the volunteers for the experience Alison explains: “We teach them about ‘nearing death awareness,’ a set of behaviors that are common among those who are near death, but can be misinterpreted as confusion or disorientation.” People who are experiencing signs of nearing death awareness may:

State that they have spoken to those who have already died.

Speak to people and see places not visible to others.

Describe spiritual beings and bright lights.

Talk aloud to people who have died before them, such as their mother, father, or close friend.

Make “out of character” statements, gestures or requests.

Describe another world of peace and beauty.

Tell you exactly when they will die.

Make hand gestures, reach for or hold unseen objects, or wave to unseen beings.

Remain open, supportive and without judgment, allowing the dying person to share whatever he or she is experiencing.

3. Have a Snack — Mundane as it sounds among matters of life and death, volunteers are encouraged to make sure they arrive at a vigil well-fed and comfortable so as not to be distracted from the moment by hunger or gnawing heat or cold.

And transition from work mode, including changing out of office clothes and silencing the cell phone, to make an emotional and spiritual shift..

4. Get Centered and Remain Present — Alison emphasizes to volunteers the importance of simply being present in the moment. “It’s so important to be comfortable with just sitting and being a presence for those who are dying,” she says. “Make sure you are centered before you enter the room, and focus on your intention, which is just to be present.”

She suggests beginning with an introduction. “Hi, I am Alison. I am here with you. I am just going to breathe with you.” And then tell the person what you are doing. “I am going to sit at your side… I am going to hold your hand.”

Abby says she sometimes reads, either silently or out loud depending on the situation, poems or meditations when she is sitting by the bedside. Alison sometimes talks and soothes, in English or Spanish, depending on the patient. But often, they and other volunteers sit in silence, stroking a hand, listening to breathing (their own and that of the patient), meditating, humming or softly singing. “It is nothing more, and nothing less, than sending love and peace to the person you’re with,” says Alison. “You don’t even have to speak it. You can communicate it in your thoughts.”

Have you ever been present at the moment of death? Please share your experience.

As we have discussed in previous posts, when someone is confronted with a potentially life threatening disease, that person’s perspective on life radically changes. In the article below, here is one psychologist’s take on lessons to be learned from someone who has cancer.

As a graduate student pursuing a degree in theology twelve years ago, I took a course called Systematic Theology — by far my toughest class. It was taught by a brilliant professor who was dying of bone marrow cancer. No one knew she was dying. She kept her diagnosis to herself and, as best as she could, covering up her chemotherapy and radiation treatments.

One afternoon she gave us this assignment: If you had only one day left of your life, how would you live it? What would you change about your life now?”

“I would drop this course,” I immediately thought to myself.

The responses were fascinating. Some people would totally rearrange their lives. A woman who worked in the admissions department said she would quit her job and start writing. Others wouldn’t adjust a thing. I was somewhere in the middle: I felt like I was generally going in the right direction, but I could certainly do without researching the Holy Trinity, because it was a mystery after all.

As a person with depression, I learn a great deal from persons suffering from terminal illnesses, because, like them, I’m never totally separated from my disease. The persistent sucker stalks me more than the lady who wants my parking space at Whole Foods, waiting for an opportunity to poke out its unsightly head. When I’ve reached a good place with my depression, I consider it merely a remission. And like cancer patients, I believe that my breakdown has changed me forever, that there is no returning to the blithe and idealistic girl I once was.

The tools that those diagnosed with cancer use to live meaningful lives even as cancer cells metastasize and replace normal tissue in their body are the same rules that help depressives forget about what’s going on in their brains and make the best of their days.

6 Life Maxims From Cancer Patients

After lots of conversations with folks battling various cancers at different stages, I’ve identified these six valuable maxims that they abide by. They are good reminders for me too.

1. One day at a time.

Or an hour at a time. Those living by an hourglass can’t afford to get tangled up in the “what ifs” of the future and the “if onlys” of the past. The sick person knows better than anyone that all he has is the moment before him. As Babatunde Olatunji once said, “Yesterday is history. Tomorrow is a mystery. And today? Today is a gift. That’s why we call if the present.”

2. Feel the fear and do it anyway, as psychologist Susan Jeffers says.

Or, as Dr. Abraham Low, founder of Recovery, Inc. would say, “Be self-led, not symptom-led.” Cancer experts have found that patients who approach their diagnosis like an athlete at a major competition fare better than those who give up and stop playing bridge on Tuesday afternoons because they are dying. For me, this means “faking it til you make it,” and forcing myself to go to the preschool social hour and pretend I am genuinely interested in hearing how Timmy’s mom potty trained the precocious boy with the M&M and sticker method when I desperately want to curl up on the couch and concentrate on how miserable I am feeling.

3. Build a strong network of support.

Family, friends, online buddies, books, therapy, support groups, church pals…all of it. Support not only makes a sickness more endurable, it can increase a person’s chances of recovery and survival.

4. Do what you love.

An older friend of mine with as many health problems as I have issues told me that the only way he has survived it all is to keep on doing the things that give him pleasure: writing and talking to retreat groups about Jesus. When people have a mission–when they feel a part of some greater purpose–their recovery rates are better. If a guy loves to fish, he ought to keep on throwing the worms out even on his bad days. And he is empowered by serving soup to the homeless on Saturday mornings or putting out a newsletter about social justice, then he shouldn’t back away from those activities even if he limps with exhaustion.

5. Think positive.

I’ve explained in several posts the brain’s “neuroplasticity,” or our ability to change the brain’s structure and neuronal connections with our thoughts. So it doesn’t surprise me that several studies have shown that positive thinking can contribute to stronger immunity, less stress and fewer toxic side effects from treatment. Kevin Stein at the American Cancer Society teaches cancer patients a three-step method to positive thinking: Stop, Think, Focus. When a patient begins to panic with thoughts like “I can’t do this,” he needs to make a conscious effort to say to himself, “Stop!” (At one point I would wear a rubber band around my wrist and snap it every time I panicked.) In the next step, he must pull out any positive aspect about his illness, such as “I’m going to be okay,” or “I have wonderful support,” or “I am a strong person,” and, finally, he must focus on those thoughts.

6. Appreciation.

You never fully appreciate what you have until it’s gone. But cancer (and depression) gives you as good of an opportunity as any to try.

There is a trend, not just in certain religious communities, to question the dangers of smartphones on our lives. It is very easy to get overwhelmed and addicted to having so much in the palm of one’s hands. Yet, the value that it has cannot be underestimated either. This article presents a good view of the good and bad related to smartphones. All I can say is that I am glad that I have Shabbat as it gives me the opportunity to shut down once a week.

It’s amazing how much has changed since the late 1980s and early 1990s when Zack Morris (a character on the TV show “Saved by the Bell”) was given a cell phone the size of a sub sandwich, and phone boxes and antennae were installed in cars so people could have a “car phone.”

It has almost fully become a new world since then. And what’s also most amusing is how much the world revolves around cell phones and their smartphone brethren — phones like the iPhone and Droid. These smartphones are now barely used as phones, but rather pocket-sized computers.

In my work as a therapist, a common theme is people’s desire to repeat the lives they were raised with. For people over roughly age 28, when they think back to their childhoods and pick out the parts they want to repeat as adults, the images that stick out don’t involve computers or cell phones. There was less to be distracted by and more focus on the present.

The ideals that I often see in sessions are very similar (each having its unique variations). The vast majority of people want a spouse or life partner, most (not all) want children, a house or large apartment, vacations with family, family dinners, secure career or job, and friends. But most want one more thing: Connection. Not via a cell phone or Internet, but emotional connection with families, friends, partners, spouses, and children.

People now have so much access and connection to other interests that it has become easy to lose sight of and become distracted from our goals and ideals. For those who are in relationships, significant attention and time spent on social media (including chatting on the computer or texting) are distracting from the connection-potential of relationships. For those who are single, it’s become much easier to fall into a daily rhythm where our companion is our smartphone or computer.

The tendency for people to isolate has significantly increased, not because it’s desired, but because it’s just too easy now. There may still be the desire for a relationship, but it’s become harder to get motivated when it’s so easy to self-entertain now.

Are Our Smartphones Helping us Live in an Alternate Reality?

The Internet and smartphones have essentially become a way of living life in an alternate reality. How much attention is spent playing with a computer or cell phone rather than spending time with family or friends, or making friendly conversation in line at the store, or on public transit? How often are we out with a person or people and find ourselves answering text messages (or watching others answer theirs), or looking at Facebook or tweeting?

There are definitely benefits to having the access we have now. But for people striving for lives that mimic an age where the best form of communication was a cordless or a corded telephone, we find ourselves dreaming of realities that are hard to fit into today’s reality. The result is an increase in disappointment that things aren’t the way people had imagined. It can be lonely at times when we have 500 friends on Facebook; however, when wanting to hang out in person no one is there because we’re not used to talking by voice or in person anymore.

We feel comforted having many friends in our Internet world, but often we forget about creating a network in our non-virtual world as well. Reality has undergone a substantial change, and now we’re left to decide how much we want to shape our realities to fit our ideals, reshape our ideals to fit today’s realities, or some of both.

Obviously, the answer isn’t to abandon our social media gadgets. The trouble comes when our doses of alternate reality and real life become out of balance to the point where the alternate reality takes over. We find ourselves interacting more with the technology in front of us — even if there’s a person on the other side — as opposed to live people, including our families.

Disconnecting From Your Smartphone and Reconnecting With Your Life

So what do we do about this? Here are a few suggestions:

Use the phone function. Smartphones have telephones! Many of us may find that an unnecessary function these days with so many ways to talk with our fingers, but make a goal to reach out to people who are important in your lives with your voice. It will increase the connection and quality of friendships and relationships, bringing them more live as opposed to behind the screen. Maybe instead of typing “Happy Birthday!” on Facebook walls, call them up.

Schedule your usage. If overuse is an issue, set specific times each day that you’ll allow yourself to be on the computer, check and respond to emails, respond to less-important texts, etc. Basically, set limits on the amount of time spent in alternate reality. (This may vary a bit if your work relies on up-to-the-minute info).

Schedule your activities. Rather than scheduling computer time, schedule free-time activities: 5pm-6pm, read; 6pm-7pm, play with the kids; 9pm-10pm spend quality time with my partner; 7pm – rest of evening, meet particular friends for drinks, etc. Scheduling the things you want to do can help ensure you’ll actually do them. Make sure to schedule the times and not only the date or activity. That’s what makes the schedule effective — not just knowing what you want to do, but when you are going to do it.

Leave your phone at home. Remember what it was like to go out and not have a cell phone or pocket computer? Try leaving your phone at home for a period of time just to take some time without being connected. Maybe take a walk without your phone, or go out for an evening without it. If you’re concerned about emergencies or need to coordinate meeting people, take your phone with you but keep it off unless you need to find your friends or are in trouble. It’s amazing the difference just turning off your phone can make.

In the end, a little disconnection hopefully will pave the way for a reconnection to those ideals and goals that are most important to you, even if those ideals were created in a world vastly different from the present.

Grief is something we never fully get through. No matter how much one is able to reframe and restructure one’s life, grief will remain on some level. Here are some thoughts to consider regarding “setbacks” with grief.

Time heals all wounds …or does it? Well intentioned comforters tell us as mourners that we need simply to be patient and allow time to heal us, but time isn’t the agent of progressing through grief. We as mourners are the agents of change and reconciliation as we make decisions and act to steer our grief journey rather than remain helpless and hopeless victims of grief. We determine not to passively let grief happen to us. Despite the overwhelming waves of sadness and emotional turmoil that routinely return to crash down on us, we decide to take a more active approach to preparing for and responding to our grief and its difficult, painful emotions. That’s why we reach out to our support systems, dig deep into resources available in our faith and beliefs, and seek help in support groups or professional counseling in our community.

We do need to be patient with ourselves and our grief because the healthy grief journey has its own timetable. W e need to give ourselves and our grief time and space for opportunities to “move forward’ and heal. But the problem is that we want to get over the rough spots in grief quickly and return to a more “normal” life or at least a life where we experience joy and hope once again. And we want it now. That change will happen. When will it happen for you? No one can predict that, but it will happen if you just keep doing what is right and healthy for you in your unique grief. Sometimes though to do what is right and healthy for you, you have to reach outside of yourself for the help and information you require.

You may find this hard to believe, but you are the expert in your grief experience. Although other mourners may share similar experiences and emotions and bereavement specialists may gather reams of data from thousands of case histories of grief, only you experience your loss and its impact personally. Other mourners and bereavement specialists are not your grief experts, you are. That’s why it is important for you when you reach out for help, comfort and encouragement to share the details of your specific grief experience and your specific needs. Only then when they hear and understand where you are in your grief can these outside experts help you.

Please don’t become discouraged when you have an unexpected, devastating grief outburst and your grief appears to be having a major setback. Don’t let that grief outburst make you feel like your attempts to steer your grief journey have been unproductive or useless. Often the progress made in grief is made in slow, miniscule and imperceptible steps forward. Mourners who keep grief diaries and journals often tell me that going back to read early entries in their grief stories helps them to understand that they are making huge changes in their grief and mourning over the long haul one small step at a time. During weeks, months, and years these small steps forward in grief accumulate creating monumental changes.

So some good advice to getting through grief in a healthy way is to be patient with yourself and your grief. Also remember you are your own grief expert. You are the most powerful agent of change and healing. You, the decisons you make and the actions you take are the secret to getting through your grief in a healthy way.

Share your grief experience with others who can help, support, and encourage you. Then decide to do what is right and healthy for you. And don’t be afraid to ask for help when what you choose and try doesn’t seem to work.

Healing and grief reconciliation will come…just not as quickly as you may want.

Written by Larry M. Barber, LPC-S, CT, author of the grief survival guide “Love Never Dies: Embracing Grief with Hope and Promise” Available on http://grief-works.org/book.php. Also available on Amazon.com, Barnes & Noble, and your local bookstore. Available now for Nook and Kindle.

Robert H. Laws, a retired judge in San Francisco, and his wife, Beatrice, knew it was important to have health care directives in place to help their doctors and their two sons make wise medical decisions should they ever be unable to speak for themselves. With forms from their lawyer, they completed living wills and assigned each other as health care agents.

They dutifully checked off various boxes about not wanting artificial ventilation, tube feeding and the like. But what they did not know was how limiting and confusing those directions could be.

For example, Judge Laws said in an interview, he’d want to be ventilated temporarily if he had pneumonia and the procedure kept him alive until antibiotics kicked in and he could breathe well enough on his own.

What he would not want is to be on a ventilator indefinitely, or to have his heart restarted if he had a terminal illness or would end up mentally impaired.

Nuances like these, unfortunately, escape the attention of a vast majority of people who have completed advance directives, and may also discourage others from creating directives in the first place.

Enter two doctors and a nurse who are acutely aware of the limitations of most such directives. In 2008, they created a service to help people through the process, no matter what their end-of-life choices may be.

The San Francisco-based service, called Good Medicine Consult & Advocacy, is the brainchild of Dr. Jennifer Brokaw, 46, who was an emergency room physician for 14 years and saw firsthand that the needs and wishes of most patients were not being met by the doctors who cared for them in crisis situations.

“The communication gap was huge,” she said in an interview. “The emergency room doctor has to advocate for patients. I felt I could do that and head things off at the pass by communicating both with patients and physicians.”

Sara C. Stephens, a nurse, and Dr. Lael Conway Duncan, an internist, joined her in the project. Ms. Stephens flew to La Crosse, Wis., to be trained in health care advocacy at Gundersen Lutheran Health System. Through its trainees, tens of thousands of nurses, social workers and chaplains have been taught how to help patients plan for future care decisions.

“People often need help in thinking about these issues and creating a good plan, but most doctors don’t have the time to provide this service,” said Bernard Hammes, who runs the training program at Gundersen Lutheran. “Conversation is very important for an advance care plan to be successful. But it isn’t just a conversation; it’s at least three conversations.”’

“People need to sit down and decide what kind of care makes sense to them and what doesn’t make sense, and who would be the best person to represent them if they became very ill and couldn’t make medical decisions for themselves,” Dr. Hammes said.

“If, for example, you had a sudden and permanent brain injury, how bad would that injury have to be for you to say that you would not want to be kept alive? What strongly held beliefs and values would influence your choice of medical treatment?”

Divisive family conflicts and unwanted medical interventions can be avoided when people specify their wishes, he said. His own mother “told us that if she had severe dementia, it would be a total waste of her life savings to keep her alive. She would rather that her children got the money.”

“We help people work through the decision process and involve those close to them so that the family shares in their goals,” Dr. Hammes said. “When patients have a care plan, the moral dilemmas doctors face can be prevented.”

At Good Medicine in San Francisco, Dr. Brokaw and her colleagues have thus far helped about two dozen people explain their goals and preferences, at a cost of $1,500 for each person.

“In today’s health care systems, families will be asked when patients can’t speak for themselves and many families are very unprepared to make these decisions,” she said.

Her colleague Ms. Stephens pointed out that only about a quarter of American adults have advance care directives of any kind, and only half of them have them in hand or know where they are should they be needed.

Furthermore, only 12 percent had any input from a physician when filling out the forms, which are often done alone or with a lawyer.

“Your lawyer shouldn’t be writing a medical contract any more than you’d want your doctor to write a legal contract,” Dr. Brokaw said.

The kinds of questions she said people should consider: What was your state of health at the start of the illness? What state are you likely to be in at the end of the illness? What, if anything, can provide a soft landing?

Proper Planning Helps Avoid Troubles

Judge Laws writes in the directive he is preparing, “After family, I value clarity of mind and the capacity to make decisions. To live well is to continue to possess the ability to converse, to read, to retain what I learn and to coherently reflect and understand. I do not want my life prolonged if I undergo a marked lessening of my cognitive powers.”

Judge Laws also does not want “to live with severe, distracting pain.”

His directive will request that any treatment he receive be compatible with those goals. He also writes that he expects his sons and his wife to support his decisions even if they disagree with them and not to let any quarrels over his care cause a rift in the family.

Studies have shown that advance care planning reduces stress on patients, their families and health care providers. It also results in 30 percent fewer malpractice suits, greater patient and family satisfaction, and a lower incidence of depression, drinking problems and other signs of complicated grief among survivors.

Ms. Stephens said that advance directives are “organic documents that can be changed at any time if circumstances or a person’s wishes change.” They should be reviewed at least once every 10 years, she added.

I wonder if this true. Are drs. less likely to recognize the mental health challenges associated with diagnosis when family is present? I would have to assume this might either a means for a doctor to avoid the deep subjects or it might be due to the patient not being as expressive when others are around as a means of protecting family from further emotional turmoil. According to this study, there are consequences to having family present during health exams, though it is possible the benefits still outweigh the harm.

Existing research shows that it is beneficial to have a loved one present when visiting the doctor, but a new study led by researchers at the Johns Hopkins Bloomberg School of Public Health suggests the opposite may be true for older adults suffering from poor mental health. They examined whether companion presence in routine primary care visits helps or hinders physician visit processes and found that older adults with poor mental health function may experience more communication challenges in the form of shorter visits and less patient-centered communication. The results are featured in the June 2012 issue of Journal of General Internal Medicine.

“Despite a growing body of research that a family companion has favorable implications for patient- centered processes and communication during medical visits, what remains unclear is the effect on medical visits that involve discussion of a potentially stigmatizing condition such as mental health,” said Jennifer Wolff, PhD, lead author of the study and an associate professor with the Bloomberg School’s Department of Health Policy and Management. “Our study found that when patients with poor mental health were accompanied by a family companion, patients engaged in less psychosocial information-giving; physicians engaged in less question-asking and partnership-building and both patients and physicians contributed more task-oriented and biomedical dialogue which is indicative of less patient-centered communication.”

“Patient-centered care remains the ideal patient provider paradigm,” said Debra Roter, DrPH, MPH, co-author of the study and a professor with the Bloomberg School’s Department of Health, Behavior and Society. “Our findings speak to the need for greater attention to primary care infrastructure to support delivery of mental health care, as well as research to identify best practice strategies for integration of family in routine medical practice. New models of inter-professionalism which acknowledge family in the decision-making environment, explicit recognition of family in national health care quality deliberation and growing evidence that family companions are commonly present and directly involved in medical-visit dialogue make this a topic ripe for further inquiry.”